| Doctor Name: | TANISHA PENN MOORE |
| NPI Number: | 1295018034 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LADC |
| License Number: | 917 |
| Business Practice Address: | 2727 S 137th West Ave Sand Springs, OK - 740635017 |
| Business Phone Number: | 9182450231 |
| Business Fax Number: | 9182415031 |
| Mailing Address: | Po Box 1101, TULSA |
| State: | OK |
| Postal Code: | 741011101 |
| Phone Number: | 9182450231 |
| Fax Number: | 9182415031 |
| NPI Enumeration Date: | 09/27/2011 |
| NPI Last Update Date: | 11/29/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 917 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OK |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |